Provider Demographics
NPI:1316323314
Name:LIFESTYLE THERAPEUTIX
Entity type:Organization
Organization Name:LIFESTYLE THERAPEUTIX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:TITUS
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:III
Authorized Official - Credentials:PT
Authorized Official - Phone:256-348-2144
Mailing Address - Street 1:1660 OSCAR PATTERSON RD
Mailing Address - Street 2:
Mailing Address - City:NEW MARKET
Mailing Address - State:AL
Mailing Address - Zip Code:35761-9418
Mailing Address - Country:US
Mailing Address - Phone:256-348-2144
Mailing Address - Fax:
Practice Address - Street 1:4825 UNIVERSITY SQ
Practice Address - Street 2:SUITE 9
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35816-1826
Practice Address - Country:US
Practice Address - Phone:256-348-2144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH4539261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy